chapter 26: Upper respiratory tract stuff Flashcards
Areas of concern
nose, sinuses, pharynx, larynx, and surgery for head and neck cancer
Deviated septum
- 80% of ppl have this a little, but diagnosis is for when it’s severe
-usually bc of trauma
-fucks with airflow and sinus drainage
Mild:
-nasal congestion and frequent sinus infections
-use saline rinses, decongestants, and analgesics
Severe:
-facial pain, nosebleeds, obstruction to nose breathing
-nasal sptoplasty might be necessary
Nasal fracture
-most common facial fracture
-simple fractures are usually uni- or bi-lateral and typically have little to no displacement
-complex fractures usually involve fucking up the rest of your face bones or your spine –> can cause meningeal tearing which leaks CSF –> may manifest as clear/pink drainage after management of bleeding
other signs are crepitus on palpation and difficulty breathing
Nursing management of nasal fracture
Maintain airway!
-keep the patient sitting upright
Reduce edema!
-apply ice to face for 10-20 min intervals
Control pain!
-give ordered analgesics (acetominophen or aspirin are goo NSAIDs for first 48 hrs)
Relieve stuffieness!
-nasal decongestants, saline nasal sprays, and a humidifier
Avoid complications
-no hot showers, alc, or smoking for first 48 hrs
Doctor management of nasal fractures
simple ones can be manually reset
complex ones –> you gotta wait 5-10 days for the swelling to go down
(maybe antibiotics if mucosa was disrupted)
septoplasty or rhinoplasty to reestablish airways and cosmetics
CAUTION: SEPTAL HEMATOMA ^^^ RISK FOR DEFORMITY AND INFECTION
Rhinoplasty
-surgery to improve airway func or for cosmetics
-patient will likely be concerned ab body image
-incisions are inside nose –> sonic rhinoplasty uses ultrasonic device to aspirate bone
-pack (1-2 days) and cast (1-2 weeks) the new nose
Special precautions before and after nasal surgery
Before
-Stop aspirin and NSAIDs 5-14 days before to reduce bleeding
-Stop smoking for a bit to encourage healing
After
-monitor pain, surgical site, and airway patency
-teach ab activity restriction: no nose blowing, swimming, heavy lifting, hard core workouts
***sometimes cosmetic endgoal takes a year
Epistaxis
who gets them?
why do they happen?
which ones are harder to treat?
ppl over 50
HTN, trauam, low humidity, URT infections, allergies, sinusitis, foreign bodies, chem irritants, anatomic malformations, tumors
posterior ones are harder to treat bc they’re far back and its hard to see how much blood is lost –> happens more in older adults
How to treat nose bleeds
-sit up, lean forward, hold nose for 5-15 mins, dont panic, get help if still bleeding
Anterior
-shove tampon with anesthetics or vasoconstrictive agents up there
-can also shove absorbent stuff up there –> “gelatin” stuff
-silver nitrate or thermal caterization
Posterior
-shove stuff deeper –> sponges, epistaxis balloons, 10-14F foley catheter w/ balloon
-2-3 days
-it hurts! give analgesics
-antibiotics bc of impaired mucosa
-nasal sling under nares
Post nose bleed care
cleanse and lube with water-soluble jelly
-teach ab saline nasal spray and humidifier
-caution agains aspirin and NSAIDs and nose blowing/extreme exercise for 4-6 weeks
Allergic rhinitis
-seasonal
-perennial
episodic
intermittent
-persistant
inflammation of nasal mucosa in response to allergen
-Seasonal = spring and fall from pollen and plants
-Perennial = year round
-episodic = sporadic exposure to allergen–> not part of every day life
-intermittent = symptoms are there less than 4 days a week or 4 weeks a year
-persistent = more than 4 days a week or 4 weeks a year
science behind allergic rhiitis
-after initial exposure to allergen, the body makes IgE against it
-at subsequent exposures, mast cells and basophils make histamie, cytokines, PGs, and leukotriens
-4 to 8 hrs later, inflammatory cells go to nasal tissue causing and miantainig allergic reponse
some ppl think its a recurrent cold
manifestations of allergic rhinitis
-sneezing, watery/itchy eyes/nose, poor smell, thin/watery nasal drainage
-nasal turbinates are pale, boggy, and swollen
-turbinates fill and press against nasal septum –> can obstruct sinus drainage (sinusitis)
-nasal polyps and post nasal drips = cough
Allergic rhinitis treatment
identify and avoid allergen
nasal corticosteroid sprays!!!
oral meds: H1 antihistamies, decongestants, leukotriene receptor antagonists
intranasal meds: anitihistamines, anticholinergics, corticosteroids, cromolyn, and decongestants
immunotherapy (allergy shots) if specific, unavoidable allergen can’t be effectively treated
which antihistamines are better?
second generation –> they don’t cause sedation
Acute viral rhinopharyngitis
common cold / nasopharyngitis
-most prevalent infectious disease –> ppl get 1-3 per year
usually coronavirus, RSV, or enterovirus
-droplet (and kinda contact) spread –> worse with overcrowding
-symptoms start 2-3 days aft infection and last up to 2 weeks
risk factors = fatigue, stress, allergies, immunocomprimise
How to treat acute viral rhinopharyngitis
-rest, fluids, antipyretics, analgesics
for sore throat
-warm salt gargles, ice chips, lozenges, or sprays
for cough
-antihistamie and decongestant therapy reduce postnasal drip
-dont use decongestant spray more than 3 days –> rebound congestion
vit C, echinacea, and zinc aren’t proven to help
Teach patients to recognize signs of secondary bacterial infections
complications of acute viral rhinopharyngitis
acute bronchitis
sinusitis
otis media
tonsilitis
pneumonia
Go to HCP if symptoms last over 2 weeks
Influenza
Super contagious rep illness that kills ppl –> GET VACCINATED
4 serotypes: A, B, C, and D
droplet spread
incubation = 1-4 days (peak contagiousness on day 3)
symptoms last 5- 7 days
Influenza A
most common
has 2 surface proteins: H helps enter cell; N helps w/ cell-to-cell transmission
infects a lot of animals
mutates to affect humans –> causes pandemic or epidemic bc ppl’s immune systems aren’t used to it
Influenza B and C
B and C only affects humans
No subtypes
B sometimes causes epidemics, but milder than A
C causes mild symptoms, but not epidemics
D only affects animals
Influenza manifestations: complicated and uncomplicated
uncomplicated:
-similar to a cold
- abrupt onset
-headache, cough, sore throat fatigue
-normal breath sounds and chest ascultation
complicated:
-pneumonia from primary influenza or secondary bacterial infection (and ear/sinus infection)
-dyspnea and crackles
-if bacterial pneumonia, influenza gets better, but cough and purulent sputum gets worse
diagnosing influenza
-not using viral cultures as much
Rapid influenza diagnostic tests (RIDTs)
-can detect influenza from resp secretions in 5 mins
-best if done w/in 48 hrs of symptoms onset
-sometimes inaccurate
contraindictions to influenza vaccine
severe allergic reactions to past ones
egg allergy –> there’s alternatives for ppl like this though
anitviral meds for influeza
Neuraminidase inhibitors preventing spread to other cells
Zanamivir (Relenza) –> inhaler
Oseltamivir (Tamiflu) –> capsule
Peramivir (Rapivab) –> IV
New drug
baloxavir marboxil (Xofluza) –> PA endonuclease inhibitor that stops viral replication –> oral
Sinusitis
Affects 1/7 adults –> inflammation blocks ostia to sinuses
-build up of fluid in sinuses promotes bacterial infections
-often follows URT infection where ciliary action is decreased
If symptoms worsen after 3-5 days or last longer than 10 days, secondary bacterial infection is probably present (5-10% of the time) –> streptococcus pneumonia, moraxella, haemophilus influenzae
Sinusitis
-acute
subacute
-chronic
Acute = starts within 1 week or URT infection and lasts less than 4 weeks
Subacute = lasts 4-12 weeks
Chronic = longer than 12 weeks –> usually associated with allergies and nasal polyps –> happens after a bunch of acute ones permanently fuck up cilia
Acute sinusitis manifestations
pain over sinus
purulent drainage
nasal obstruction
congestion
fever
malaise
headaches
halitosis
chronic sinusitis manifestations
-also risk factors/correlations
nonspecific
rarely febrile
facial pain, nasal congestion, increased drainage –> not severe pain or purulent shit
nasal endoscopy, xray, CT scan confirm
Asthma, GERD, smoking
management of sinusitis
decongestants/ saline nasal spray
intranasal corticosteroids
analgesics
Amoxicilin if bacterial infection
-if that doesn’t help after 2 weeks, add in clavulanate, fluoroquinolone, or cephalosporin
If chronic, broad spectrum antibiotics for 4-6 weeks
Surgery and propel implant (dissolves after 30 days) if hypertrophy or septal deviation is the cause
Nasal polyps
soft, painless growths from repeat inflammation of sinus or nasal mucosa
-yellow, gray, or pink grape-like things
If big, can cause nasal obstructio, nasal discharge, and speech distortion –> fix wtih corticosteroids or endoscopic/laser surgery
Foreign bodies
inorganic = plastic or metal –> no symptoms
organic = food –> inflammation, nasal discharge with bad smell
pain, difficulty breathing, nasal bleeding
blow it out- don’t irrigate bc that’ll push it back in
Acute pharyngitis
inflammation of pharyngeal walls
-may include tonsils, palate, and uvula
-can be viral, bacterial, or fungal
viral = 90% of the time
bacterial = 5-10% —-> strep throat from beta-hemolytic streptococci
fungal = after long antibiotic or corticosteroid use –> also immuno supressed ppl
Other causes = dry air, smoking, GERD, allergies, intubation, chems, cancer
Acute pharyngitis manifestation
-red, swollen throat
If bacterial:
-fever over 100.4
-anterior cervical lymph node enlargement
-tonsillar or pharyngeal exudate
-absence of cough
white irregular patches = candida albicans
caring for acute pharyngitis
if strep throat, pennicilin several times a day for 10 days to prevent rheumatic fever
-other antibiotics are ok too: erythromycin, clindamcin, azithromycin
-person is still contagious til they’ve been on meds 24-48 hrs
candida is treated with nystatin –> swish around mouth
ibuprophin or acetominphen for pain
peritonsilar abcess
complication of tonsilitis
-usually from strep
-pain, swelling, throat blocking
fever, chills, leukocytosis, difficulty swallowing, muffled voice
treatment = IV antibiotics, needle aspiration, or incision and drainage of abcess –> sometimes emergency tonsillectomy
Laryngeal Polyps
develop on vocal cords from vocal abuse or irritation
-hoarseness is main thing
-treat with voice rest and hydration
Big ones cause dysphagia, dyspnea, and stridor –> might need surgery
Acute laryngitis
swelling and inflammation of voice box
-usually viral, but can also be from overuse of voice or exposure to irritants
tingling or burning in back of throat is main thing
-also fever, cough, feeling of fullness in throat
-symptoms shouldn’t last more than 3 weeks
treatment of acute aryngitis
dont talk or sing –> kinda impossible –> whispering makes it worse though so idk
-acetaminophen, cough suppressants, lozenges, and humidifiers can help
-hydration is good; caffeine, smoking, and alc are bad
Airway obstruction
manifestations
-choking, stridor, use of accessory muscles, intercostal retraction, nostril flaring, wheezing, restlessness, tachycardia, cyanosis, and change in LOC
Gotta have an airway w/in 3-5 mins to prevent permanent brain damage
Interventions = heimlich, cricothyroidotomy, ET intubation, or tracheostomy
Tracheostomy
shorter and wider than ET tube:
-lower infection risk, more comfy, less risk of vocal cord damage
Similar to cricothyroidotomy, but done in OR rather than emergencies
Newer technique = percutaneous tracheostomy where you open the hole progressively to prevent bleeding and other complications
pieces of tracheostomy tubing
flange = faceplate
obturator = helps insert tube
outer cannula = keeps airway patent
inner cannula
cuffs w/ balloons = ensure airway is open (usually if breathing mechanically)
fenestrations in cannulas = allow for spontaneous breathing and talking
Nursing prep before tracheostomy
explain procedure
make sure all personel and equipment are there
-bag-valve-mask, bedside suction, IV
take vitals
put patient supine
give analgesia
After tracheostomy
inflate cuff –> confirm w/ auscultaion of chest, end tidal CO2, ad air through suction catheter
remove ET tube
monitor vitals and ventilator settings
chest xray
how often to check, clean, and dress tracheostomy
check at least once per shift
dress and clean every 12 hrs
management of tracheostomy balloon and suction post surgery
check pressure every 8 hrs
pressure shouldn’t exceed 20-25 –> don’t want to damage tracheal mucosa
don’t do suction during first couple hours
-give humidified air to compensate for loss of moisture
changing tapes and tubes of tracheostomy
change tape 24 hrs after procedure –> 2 person job
HCP can change tubes no sooner than 7 days after tracheostomy
-keep tube of equal or lesser size by bed
what to do if tracheostomy tube gets dislodged?
call for help
assess patient for resp distress
use hemostat to spread opening where tube was isplaced
put obturator in replacement tube, lube with saline, and insert into stoma
take out obturator
OR
-stick suction catheter in and thread tracheostomy tube over the catheter
-remove suction catheter
-only ok to do if stoma is older than a week –> if not, semi fowler’s position
-cover stoma with dressing and ventilate
Tracheostomy long term care
-how often to change?
-swallowing
change after 1 month the first time, then every 1 to 3 months after that
inflated cuff might cause swallowing probs –> assess for aspiration with videofluoroscopy or fiberoptic endoscopy –> leave cuff deflated or use cuffless tube if it helps
Passy-Muir valve
-attaches to hub of tracheostomy tube
-when cuff’s deflated, valve moves air through vocal cords on exhalation
-inhalation still happens through tube
Decannulation requirements
- hemodynamic stability
- have an intact, stable respiratory drive
- be able to adequately exchange air
- independantly expectorate secretions
steps for decannulation
-suction the tube and make sure there’s no oral secretions
-loosen or cut tracheostomy tape and remove sutures
-MAKE SURE CUFF IS DEFLATED
-pull out in one smooth motion, but stop if resistance
-apply sterile dressing and moitor for bleeding
Head and neck cancer basics
affects nasal cavity, sinuses, pharynx, larynx, oral cavity, and salivary glands –> usually arises from squamous cells lining the mucosa
-smoking and alc are big contributors
-ppl over 50! (if under 50, assoc w/ HPV)
head and neck cancer manifestations
-soar throat
-hoarseness lasting more than 2 weeks
-ear pain/ ringing in ears
-swelling or lumps in neck
-constant coughing/ coughing up blood
-difficulty chewing, swallowing, moving tongue
Nursing diagnosis of head and neck cancer
Doctor stuff
inspect ears, nose, throat, mouth
-check for thickening of oral mucosa
-check for leukoplakia or erythroplakia (preceed invassive carcinoma by many yrs)
-check neck lymph nodes
Docotrs: pharyngoscopy/laryngoscopy, biopses, CT or MRI, PET
TNM staging
-size of tumor
-number of lymph nodes involved
-extent of metastasis
Surgical therapy for head and neck cancer
Vocal cord stripping - doesn’t affect voice
Laser surgery
Cordectomy - part or all of vocal cords –> affects voice
Partial or total laryngectomy - affects voice
pharyngectomy
trachostomy
lymph node removal
Neck disection surgery
-radical = all tissue from mandible to clavicle (muscle, nerve, glands, vessels)
-modified radical = lymph nodes and some tissue
-selective = fewer lymph nodes
radiation therapy for head and neck cancer
-can use external beam therapy or internal implants (brachytherapy)
-Brachytherapy = put radioactive seeds in/near the tumor via a needle
Chemotherapy
-used with radiation for stages 3 and 4
-Cetuximab (Erbitux) = targeted therapy used with chemo to stop cells from growing
nutrition therapy for cancer
-might be painful or difficult to eat
-enteral feeding is important
-bland foods are more tolerable, but can add mild sauces to add cals and lubricate
-try to get as many cals as possible in bc patients are usually malnourished
-videofluoroscopic swallowing studies
WATERY STUFF LEADS TO ASPIRATION
Approaches to restore oral communication
- electrolarynx
- tracheoesophageal puncture (TEP) – Blom-Singer is most common
- esophageal speech - hard to learn; alters speech
Post-laryngectomy
-need frequent suction
-secretions change over time (check every hour and then switch to every 4 hrs)
-at first, lots of blood-tinged secretions that gradually diminish and thicken
-need adequate fluid and humidifiers
-deep breathing and coughing are good
What helps with xerostema from radiation?
-fluids
sugarless gum
sugarless candy
nonalc mouth rinses
artificial saliva
fluoride gels help prevent dental deterioration
Other considerations for radiation patients
-have block in mouth during treatment
-use warm, bland rinses 4-6 times a day
-nothing spicy, hot, or acidic
-only perscribed lotions
-walk 15-30 mins a day
stoma care
-clean daily with moist cloth
-nasal spray every 1-2 hrs prevents crusting
-remove laryngectomy tube and clean it daily along with inner canula
-cover it when coughing or doing anything that could let stuff in
-no swimming
